Inside Health

CASES

CASES; Helping AIDS Patients Have Safer Sex

By ABIGAIL ZUGER, M.D.

Published: November 24, 1998

The patient was running late; he was due at work in 20 minutes and didn't have time to chat, but he did need the doctor's help with a couple of quick problems.

First on his list was an annoying burning and discharge after urination that he worried meant he had picked up a sexually transmitted infection from a weekend sexual encounter.

And second, he needed refills on all his regular medications: the three he took for AIDS, his vitamins, and the testosterone and Viagra he took to normalize his sexual functioning.

By itself, none of his requests would have given the doctor much pause. Together, they packed a wallop. Were the patient's symptoms evidence that he was not using condoms during sexual activities -- activities that were enabled by the doctor's prescriptions, and were putting others at risk of H.I.V. infection? What were the doctor's responsibilities in this situation?

It was one of those moments that medical school seldom prepares doctors for, but that caring for people with H.I.V. infection is increasingly providing. As AIDS changes from an inevitably fatal condition to one people can live with for years, patients are struggling to readjust -- and doctors are, too. The fast-paced tragedy and heroics of dealing with catastrophic illness are fading from their workdays, which are filling instead with the less dramatic but often far more difficult tasks of helping patients with a chronic but treatable illness live normal lives.

And integrating sexual activity into those lives is probably the most complex job of all, for patients and doctors. H.I.V. infection can affect sexual and reproductive health in a variety of ways. Depression can limit sexual drive in both men and women; irregular menstruation is common in women, while in men blood testosterone levels may fall to levels far below normal, causing fatigue, weight loss and an inability to function sexually that may persist even on the powerful new AIDS drugs.

''Sexual dysfunction is very prevalent in H.I.V.-infected people,'' said Dr. Ellie E. Schoenbaum, director of AIDS research at Montefiore Medical Center in the Bronx. ''All through the epidemic we've found that patients haven't had the active sex lives or rapid partner turnover we first expected.''

In the early 1990's a series of studies showed that replacing testosterone in men with H.I.V. infection ''transformed them,'' said Dr. Judith G. Rabkin, a professor of clinical psychology at Columbia University's College of Physicians and Surgeons who worked on some of the earliest studies. Men gained muscle mass and energy, shook off depression, and sexual desire and performance became more normal.

''Testosterone is an extremely popular and effective treatment,'' she said, one that is increasingly accepted by doctors for H.I.V.-infected men and is being studied for women with H.I.V. as well.

Important in her studies, Dr. Rabkin said, was the discovery that improving men's sexual functioning with testosterone unquestionably increased the likelihood that they would use condoms.

''Before taking testosterone, a lot of men didn't use condoms because they were afraid they would lose the erection,'' Dr. Rabkin said. ''That wasn't the case afterward. So giving it to people can actually be a positive public health move.'' While Viagra is too new to have been studied extensively in H.I.V. infected men, it is also used by doctors to help patients with H.I.V. function more normally.

Against these straightforward medical facts, the behavioral facts are plain, too. Despite the ''safe sex'' and ''use condoms'' mantras that permeate AIDS counseling, in sexual matters, people with H.I.V. find it as difficult as anyone else to speak frankly to partners and to use condoms.

In a study published in February in the Archives of Internal Medicine, Dr. Michael D. Stein of Rhode Island Hospital in Providence found that 40 percent of the sexually active H.I.V.-infected people he surveyed had not told all their recent sexual partners of their infection. More than half of them also did not use condoms regularly.

''Our hope is that as survival increases and optimism about the disease increases, there will be more truthful talk about sex among infected people and their partners,'' Dr. Stein said.

Who should initiate these conversations? Is it the infected person's responsibility to tell, or the partner's responsibility to ask? Both, said Dr. Ronald J. Bayer, a professor of public health at Columbia University who has written extensively on the topic of sexual ethics in H.I.V. infection.

Medical ethicists increasingly endorse a responsibility on the part of the infected person to protect uninfected partners, as well as a responsibility on the part of partners to protect themselves, he said.

But the sexual ethics of AIDS -- complicated enough when only the participants are involved -- become even more of a tangle when a third party hovers in the background, influencing the course of events with a prescription pad.

On the one hand, the doctor's primary allegiance is traditionally to the health and well-being of his or her own patient. Still, experts in medical ethics acknowledge the obligation to protect other people who may be injured by the patient. In recent years, the courts have emphasized this obligation, finding doctors liable for failing to warn others of potential harm at the hands of their violent patients or of patients with communicable diseases.

When a doctor is treating a patient known or suspected of being sexually reckless, then the doctor may well choose to withhold medications that enable sexual activity until the patient demonstrates more responsible behavior, said Nancy N. Dubler, a lawyer and ethicist who heads the division of bioethics at Montefiore Hospital and the Albert Einstein College of Medicine in the Bronx. But even this simple decision can be a terrible mistake if a patient who occasionally neglects to use condoms becomes completely unable or unwilling to use them as a result.

The patient was late for work and wanted his prescriptions. The doctor's next two patients were jittering in the waiting room.

A physician in this situation ''has the absolute obligation to deliver a set of educational and moral warnings and information with the medication,'' Ms. Dubler said, telling the patient that his right to a normal and enjoyable sex life is balanced by ''extraordinary obligations'' to be candid with sexual partners and avoid putting them at risk.

''Look,'' the doctor said. ''I know you're in a hurry, but I can't refill these medications until we have a discussion about why you forgot the condoms last weekend, and why we have to make sure it won't happen again.''